[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-253213-105":53,"doc-detail-253213-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","employee-incident-report","Employee Incident Report","","Employee Incident Report form for documenting workplace injuries and ensuring timely notification to the business office, including cases where immediate medical care is not sought but later complications are possible. The report captures injured employee details, incident location and date, time of day, doctor or hospital information, and witness information. It requires investigation of seriousness, identification of the real cause, corrective prevention steps, and completion by the responsible reporting person. It also includes medical service and return-to-work recommendation sections for attending physicians and work restriction guidance.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/employee-incident-report/253213/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/employee-incident-report/253213.png","ImageObject",442,249,{"name":88,"@type":89},"Mia  ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-13",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"When must an employee incident report be submitted after an injury?","Question",{"text":109,"@type":110},"All incidents must be reported on an incident form and submitted to the business office within 24 hours.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What additional steps are required if the injured employee does not see a doctor immediately?",{"text":114,"@type":110},"If the injury type could cause problems later, a report must still be filed even when medical care is not sought right away.",{"name":116,"@type":107,"acceptedAnswer":117},"Who completes the return to work recommendations record and what does it include?",{"text":118,"@type":110},"The attending physician completes the return to work recommendations record, including diagnosis/condition notes and whether the patient can return to work with no limitations or with specified limitations.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},253213,1789264692,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":126,"read_time":73},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","EMPLOYEE INCIDENT REPORT  \n (Print on blue paper)   \nALL INCIDENTS SHOULD BE REPORTED ON AN INCIDENT FORM AND SUBMITTED TO THE BUSINESS OFFICE WITHIN 24 HOURS. IF THE INJURED EMPLOYEE DOES NOT SEE A DOCTOR IMMEDIATELY, BUT IT IS THE TYPE OF INJURY WHICH COULD CAUSE PROBLEMS LATER, A REPORT MUST ALSO BE FILED.  \nEACH INCIDENT SHOULD BE INVESTIGATED WHETHER THE RESULT WAS SERIOUS OR NOT. THE OBJECT IS TO PREVENT RECURRENCES AND IT IS ONLY BY THOROUGH INVESTIGATION THAT THE REAL CAUSE CAN BE DETERMINED AND CORRECTED.  \nNAME OF INJURED EMPLOYEE  \n\n| STREET ADDRESS |\n| --- |\n| POSITION |\n\nBUILDING/SCHOOL WHERE ACCIDENT OCCURRED  \n(Last, First, M. I.)  \n\n| CITY, ZIP CODE |\n| --- |\n| DATE OF INCIDENT |\n\nDATES ABSENT FROM WORK DUE TO INJURY  \nSOCIAL SECURITY NUMBER  \n\n| HOME TELEPHONE |\n| --- |\n| TIME OF DAY |\n\nDATE EMPLOYEE WILL RETURN TO WORK  \nGIVE A DESCRIPTION OF INJURY (TWISTED LEFT ANKLE, CUT RIGHT HAND, ETC. ):  \nDESCRIBE HOW INCIDENT OCCURRED  \nDID THE EMPLOYEE SEE A DOCTOR OR GO TO THE HOSPITAL?  YES  NO (\"X\" ONE)  \nIF YES, FILL IN THE FOLLOWING INFORMATION AND HAVE PHYSICIAN COMPLETE“RETURN TO WORK RECOMMENDATIONS RECORD”, WHICH CAN BE OBTAINED IN THE SCHOOL OFFICE OR THE BUSINESS OFFICE:  \nDOCTOR OR HOSPITAL  \nNAME   NAME   ADDRESS   ADDRESS   DATE OF SERVICE   DATE OF SERVICE    \nWERE THERE ANY WITNESSES TO THIS INCIDENT?  YES  NO (\"X\" ONE)  \nIF YES, COMPLETE THE FOLLOWING:  \nNAME OF WITNESS(ES) ADDRESS TELEPHONE  \nPLEASE ANSWER THE FOLLOWING QUESTIONS. CHECK \"YES\" OR \"NO\" . INDICATE N/A IF QUESTION DOES NOT APPLY.  \n1.  \n2.  \n3.  \n4.  \n5.  \n6.  \n7.  \n8.  \n9.  \n10.  \nWAS INJURED PERSON PROPERLY INSTRUCTED IN SAFE EFFICIENT METHODS?  \nDID HE/SHE VIOLATE ANY INSTRUCTIONS?  \nWAS NECESSARY PROTECTIVE EQUIPMENT WORN?(GOGGLES, SAFETY BELT, HARD HAT, ETC. )  \nDID POOR HOUSEKEEPING CONTRIBUTE TO THE INCIDENT?  \nDID \"HORSEPLAY\" CAUSE THE INCIDENT?  \nWAS IT CAUSED BY SOMETHING WHICH NEEDED REPAIR?  \nSHOULD A GUARD BE PROVIDED?  \nDID ANY BODILY DEFECT CONTRIBUTE TO THE INCIDENT?  \nWAS ACCIDENT CAUSED BY AN UNSAFE ACT?  \nDID INJURED PERSON REPORT TO FIRST AID IMMEDIATELY?  \nYES  \nYES  \nYES  \nYES  \nYES  \nYES  \nYES  \nYES  \nYES  \nYES  \nNO  \nNO  \nNO  \nNO  \nNO  \nNO  \nNO  \nNO  \nNO  \nNO  \nWHAT DO YOU CONSIDER THE REAL CAUSE OF THIS INCIDENT (NAME OBJECT OR  \nSUBSTANCE DIRECTLY CONTRIBUTING TO INCIDENT):    \nWHAT STEPS ARE BEING TAKEN TO PREVENT SIMILAR INCIDENTS:    \nPERSON MAKING REPORT:  \nNAME   TITLE   DATE    \nPRINCIPAL/DIRECTOR/SUPERVISOR   DATE    \n(SIGNATURE)  \n Date Received by Business Office   \nld:H:WORKERSCOMP:EMPLOYEEACCFRM2 .doc 111/07  \nAUTHORIZATION FOR EXAMINATION OR TREATMENT Worker’s Comp Related Injury  \nSCHOOL DISTRICT OF WAUKESHA (Employer)  \n222 Maple Avenue / Waukesha WI 53186 / Ph: 262-970-1031 Fax: 262-970-1020  \nName:    \nLocation:    \nSSN:   Date:    \nIf possible, please have your supervisor notify the clinic in advance of your arrival. Upon your arrival, please indicate to the reception desk that the visit is for a work related injury. Please take this form with you to the clinic.  \nLocation: 615 West Moreland Boulevard  \nWaukesha, WI 53188-2462  \nPhone: 262-896-8420  \nSchedule: 7 a. m.– 7 p. m. Monday/Wednesday  \n7 a. m.– 6 p. m Tuesday/Thursday/Friday  \n8 a. m.– 1 p. m. Saturday  \nClosed Sunday  \nMedical Service Form  \n   reported an injury on   \n(Name of Employee) (Date) while at work at the Waukesha School District.  \nThe nature of the reported injury to be treated is   \n(Nature of Injury)  \nPlease forward all bills to our Workers Compensation carrier at the address below:  \nEmployers Mutual Company 16455 West Bluemound Road PO Box 327  \nBrookfield, WI 53008-0327  \nPhone: (888) 362-2255 or (855) 495-1800  \nFax: (888) 992-6125  \nWaukesha School District is committed to preventing workplace injuries, controlling injuries that do occur, and providing modified duties after an injury. We offer many types of alternative work and/or transitional work which allows the injured employee to work within their medical res","cbCaimjldlVgte9a","https://ap.wps.com/l/cbCaimjldlVgte9a","pdf",454808,6,"English","# Employee Incident Report\n## Incident notification and investigation requirements\n## Injured employee and incident details\n## Doctor/hospital and witness information\n## Incident questions and real cause\n## Preventive steps and reporting authorization\n## Authorization for examination or treatment (Worker’s Comp Related Injury)\n## Medical service form and billing instructions\n## Attending physician return to work recommendations record","[{\"question\":\"When must an employee incident report be submitted after an injury?\",\"answer\":\"All incidents must be reported on an incident form and submitted to the business office within 24 hours.\"},{\"question\":\"What additional steps are required if the injured employee does not see a doctor immediately?\",\"answer\":\"If the injury type could cause problems later, a report must still be filed even when medical care is not sought right away.\"},{\"question\":\"Who completes the return to work recommendations record and what does it include?\",\"answer\":\"The attending physician completes the return to work recommendations record, including diagnosis/condition notes and whether the patient can return to work with no limitations or with specified limitations.\"}]","Employee Incident Report | PDF"]